• John Dawson, Dirk Kiner, Warren Gardner, Rachel Swafford, and Peter J Nowotarski.
• *Baylor College of Medicine, Houston, TX; and †University of Tennessee College of Medicine-Chattanooga, Chattanooga, TN.
• J Orthop Trauma. 2014 Oct 1;28(10):584-90.

ObjectivesThis study was performed to compare patient outcomes after Reamer-Irrigator-Aspirator (RIA)-harvested bone grafting with the current gold standard, either anterior or posterior iliac crest bone graft (ICBG).DesignProspective randomized controlled trial.SettingMulticenter study at 3 geographically separate Level 1 trauma centers.Patients/ParticipantsOne hundred thirty-three patients with nonunion or posttraumatic segmental bone defect requiring operative intervention.InterventionPatients were prospectively randomized to receive ICBG or RIA autograft. Supplemental internal fixation was performed per surgeon preference.Main Outcome MeasurementsOperative data included amount of graft, time of harvest, and associated surgical costs. The Short Musculoskeletal Functional Assessment and the Visual Analog Scale were used to document baseline and postoperative function and pain. Clinical and radiographic union was the defined end point; patients considered to have failed treatment if they either developed an infection requiring operative treatment or had a persistent nonunion of the grafted extremity.ResultsOne hundred thirteen of the 133 enrolled patients were followed until union and included in the final analysis. Intraoperative data showed anterior ICBG to yield 20.7 ± 12.8 (5-60) cm of autograft with an average harvest time of 33.2 ± 16.2 minutes, posterior ICBG yielded 36.1 ± 21.3 (20-100) cm of autograft in 40.6 ± 11.2 minutes, and RIA yielded 37.7 ± 12.9 (5-90) cm in 29.4 ± 15.1 minutes. Anterior ICBG produced significantly less bone graft than either RIA or posterior ICBG (P < 0.001). The RIA harvest was completed in significantly less operative time compared with posterior ICBG (P = 0.005). At $738, the RIA setup was considerably more expensive than the ∼$100 cost of a bone graft tray; however, when compared with posterior ICBG, the longer operative time required for a posterior harvest came at an additional incremental cost of $990-1880, making RIA the less expensive option. Patients were followed for an average of 56.9 ± 42.1 (11-250) weeks. Forty-nine of 57 patients (86.0%) who received ICBG united in an average of 22.5 ± 13.2 weeks; 46 of 56 patients (82.1%) who received RIA healed in an average of 25.8 ± 17.0 weeks. Union rates and time to union were comparable between the 2 procedures. There was no difference in complications requiring reoperation for persistent nonunion or infection at the grafted site, nor there was any difference in donor-site complications. Postoperative follow-up showed that RIA patients had significantly lower donor-site pain scores throughout follow-up.ConclusionsWhen compared with autograft obtained from the iliac crest, autograft harvested using the RIA technique achieves similar union rates with significantly less donor-site pain. RIA also yields a greater volume of graft compared with anterior ICBG and has a shorter harvest time compared with posterior ICBG. For larger volume harvests, cost analysis favors using RIA.Level Of EvidenceTherapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

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